Certification Application – American Association of Couples and Sex Therapists

Certification App

First Name

Last Name

Address

City

State

Zip Code

Country

Website URL

Degree

Field of Study, Insitution, and Year degree was awarded:

License

License Number:

Professional Experience (most recent first)

I have completed the following certification requirements:

Attended the entire year long Couples and Sex Therapy Training Program, which includes Inter-Analytic Couples Therapy courses, Human Sexuality, Sex Education and Sex Therapy courses, and the Case Consultation Course twice.

Presented three cases in the Case Consultation Course to demonstrate training, skills and knowledge

I am a member in good standing of AACAST

I have read and agree to abide by the AACAST Code of Ethics. By signing the application for certification form, I agree to be bound by the AACAST Code of Ethics.

I have attached a copy of a valid state license in at least one of the following fields: marriage and family therapy, psychology, social work, counseling, medicine, or nursing.

I waive any claim to confidentiality of the material stated herein. Further, I agree that I am submitting this application voluntarily and indemnify and hold harmless AACAST or any of its directors, officers, members or agents.

Date

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First Name

Last Name